Health care-associated infections in Iran: A national update for the year 2015

Healthcare-associated infections in Iranian pediatric and adult intensive care units: A comprehensive review of risk factors, etiology, molecular epidemiology, antimicrobial sensitivity, and prevention strategies during the COVID-19 pandemic

The current review article provides a comprehensive analysis of nosocomial infections in pediatric and adult intensive care units (ICUs) in Iran. We examine the risk factors and etiology of nosocomial infections, with a particular focus on molecular epidemiology and antimicrobial sensitivity. In this article, we explore a range of prevention strategies, including hand hygiene, personal protective equipment, environmental cleaning, antibiotic stewardship, education, and training. Moreover, we discuss the impact of the COVID-19 pandemic on infection control measures in ICUs and provide valuable insights for healthcare professionals and policymakers seeking to address this critical public health issue. In conclusion, this review article can serve as a valuable resource for those interested in understanding and improving infection control in ICUs and beyond.

Incidence, accuracy, and barriers of diagnosing healthcare-associated infections: a case study in southeast Iran

BACKGROUND

Healthcare-associated infections (HAIs) are a threat to patients. Accurate surveillance is required to identify and prevent HAIs. To estimate the incidence rate, report the accuracy and identify the barriers of reporting HAIs using a mixed-method study.

METHODS

In this quantitative study, we externally evaluated the incidence rate and accuracy of the routine surveillance system in one of the main hospitals by an active follow-up of patients from September to December 2021. We used in-depth interviews with 18 experts to identify the barriers of the routine surveillance system.

RESULTS

Among 404 hospitalized patients, 88 HAIs were detected. The estimated rate of HAIs was 17.1 (95% Confidence Intervals 95: 14.1, 21.1) per 1000 patient-days follow-up. However, in the same period, 116 HAIs were reported by the routine surveillance system, but the agreement between the two approaches was low (sensitivity = 61.4%, specificity = 82.6%, negative predictive value = 89.7%, and positive predictive validity = 46.5%). The minimum and maximum positive predictive values were observed in urinary tract infection (32.3%) and surgical site infection (60.9%). The main barrier of reporting HAIs was lack of cooperation in reporting HAIs by infection control link nurses and laboratory supervisors.

CONCLUSIONS

The discrepancy between the longitudinal study findings and the routine surveillance might be related to the inaccessibility of the surveillance system to clinical information of patients. In this regard, decreasing the barriers, increasing the knowledge of infection control nurses and other nurses, as well as the development of hospital information systems are necessary.

Challenges of and corrective recommendations for healthcare-associated infection's case findings and reporting from local to national level in Iran: a qualitative study

Background

The accuracy of health care−associated infections (HAIs) statistics in many countries is questionable and the main reasons of this inaccuracy are not well-known. The study aim was to explore inhibitors of and corrective recommendations for HAIs case findings and reporting in some of Iran hospitals.

Methods

Sixteen face-to-face interviews and an expert panel were performed with expertise of infection prevention and control (IPC) programs in hospitals, and Deputies of Health and Treatment in medical university and Ministry of Health from Feb 2018 to May 2019. Using conventional content analysis, code, subcategories and categories were developed.

Result

Three categories emerged including improper structure preparation, conflict of interest, and inadequate motivation. Allocating distinct budget and adequate staff to IPC programs, developing a user-friendly surveillance system and engaging physicians and nurses for HAIs reporting are the main corrective recommendations accepted by the expert panel.

Conclusion

Despite the improvement in growing case-findings and reporting of HAIs in Iran, there are many challenges which inhibit accurate case finding and reporting of HAIs. So it is necessary to update the structure, system and rules to reach accurate HAIs data in Iran.

Knowledge and perception of hand hygiene: A survey using WHO standardized tools in Tehran, Iran

BACKGROUND

Proper hand hygiene is the most important action in preventing healthcare-associated infections (HCAIs). In this study, the knowledge and perception of hand hygiene assessed among nurses as the most exposed personnel to patients.

METHODS

In this analytical cross-sectional study, the nurses working in different wards of a collegiate tertiary hospital in Tehran were investigated by standardized WHO questionnaires.

RESULTS

Of the 101 participating nurses 89 (88.1%) were females. 81 (80.2%) had received formal related training. The 69 respondents estimated the mean prevalence of HCAI to be 38.91% and 98 (97.1%) considered hand hygiene an effective prevention in this regard. 78 (77.3%) perceived hand hygiene as the center priority; 82, 83 and 79 of participants would think that good hand hygiene matters for their superiors, colleagues and patients, respectively. The practice of hand hygiene was stated to be difficult by 48 (47.5%) respondents. There was no significant difference in self-reporting of hand hygiene practice among nurses in age (P=0.68), the degree of education (P=0.574), work experience (P=0.64), nor their wards (P=0.131). There was a significant reverse relationship with the supposed difficulty level of doing hand hygiene (P=0.049). The mean score of the nurses' knowledge was 66.53 (±9.41) based on the answers to the questions of the knowledge questionnaire.

CONCLUSION

Knowledge and perception of hand hygiene, as this study showed, might not to be satisfactory; therefore, planning to improve these indicators and regular monitoring using standard tools is necessary for all healthcare centers.

Frequency and co-colonization of vancomycin-resistant Enterococci and Candida in ICU-hospitalized children

In the time span between January 2018 and September 2020, 205 patients were enrolled in a prospective cohort study at Mofid Children's Hospital. Demographic information and clinical data on all the participating children were collected and rectal swabs were performed for the sampling method. All samples were analysed so as to identify the presence of Enterococcus and Candida colonization by the use of conventional biochemical tests. Resistance to vancomycin in Enterococcus isolates was phenotypically identified using an E-test kit and MIC value, interpreted according to the CLSI criteria. The presence of vanA and vanB genes, which encode the resistance to vancomycin, was screened by PCR assay. Candida species were detected in 21.5% of rectal swab samples. Candida glabrata (56.8%) and Candida albicans (43.2%) were the only Candida species detected. Enterococcus species were detected in 29.3% of rectal swab samples. Out of 60 Enterococcus isolates, 33 (55%) were resistant to vancomycin. Moreover, vanA was detected in 84.8% and vanB was detected in 3% of the 33 vancomycin-resistant Enterococcus isolates. Enterococcus and Candida species were frequently detected in the <1 year and 1–3 years age groups, respectively. Central venous access catheter and brain tumour were the main reasons for hospital admissions, 32.2% and 20.1% of total admissions, respectively. Furthermore, it must be noted that the most frequent underlying medical conditions in participating patients were esophageal atresia and hydrocephalus. The results of the present study demonstrated the necessity of determining the susceptibility of Enterococcus isolates to vancomycin before prescribing antibiotics.

Rate of the incidence of hospital-acquired infections in Iran based on the data of the national nosocomial infections surveillance

Hospital-acquired infections (HAIs) lead to increased length of hospital stay, inappropriate use of broad-spectrum antibiotics and multiple antibiotic resistance. This study aimed to investigate the rate of HAIs in Iran. In this multi-centre study, the rate of HAIs was calculated based on the data collected through Iranian nosocomial infections surveillance for patients with HAIs, as well as through hospital statistics and information systems on hospital-related variables. Data were analysed using Stata software; in addition, ArcGIS was used for plotting the geographical distribution of HAIs by different provinces. The mean age of the 107 669 patients affected by HAIs was 52 ± 26.71 years. Just over half (51.55%) of the patients were male. The overall rate of HAIs was 26.57 per 1000 patients and 7.41 per 1000 patient-days. The most common HAIs were urinary tract infections (26.83%; 1.99 per 1000 patient-days), ventilator-associated events (20.28%; 1.5 per 1000 patient-days), surgical-site infections (19.73%; 1.45 per 1000 patient-days) and bloodstream infections (13.51%; 1 per 1000 patient-days), respectively. The highest rate of HAIs was observed in intensive care units. Device, catheter and ventilator-associated infections accounted for 38.72%, 18.79% and 16% of all HAIs, respectively. Based on the results, HAIs are common in intensive care units, and urinary tract infections and device-related infections are more prevalent in Iran. To reduce HAIs it is recommended to implement appropriate policies and interventions, train staff about the use of devices, and prepare and update protocols and guidelines for improving the quality of care.

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The overall rate of HAIs was 26.57 per 1000 patients and 7.41 per 1000 patient-days.

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Hospital-acquired infections are common in ICU wards, while UTIs and device-related infections are more prevalent in Iran.

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Device, catheter and ventilator-associated infections accounted for 38.72, 18.79%, and 16% of all HAIs, respectively.

"Infection prevention and control idea challenge" contest: a fresh view on medical education and problem solving

Background

Healthcare-associated infections (HAIs) challenge modern medicine. Considering their high prevalence in Iran, we aimed to provide knowledge on the subject, and to teach about the importance of infection prevention and control (IPC) to a broad audience of pre-graduate healthcare professionals, focusing on education as the cornerstone of IPC.

Main body

We invited Iranian medical students to present ideas on “how to reduce HAIs.” Projects were eligible if being original and addressing the call. Accepted projects were quality assessed using a scoring system. Forty-nine projects were submitted, of which 37 met the inclusion criteria. They had a mean score of 69.4 ± 18.3 out of the maximum possible score of 115. Four reviewers assessed the 37 projects for clinical applicability, impact on patient safety, and innovation, and selected the best 12 to compete at the 2nd International Congress on Prevention Strategies for Healthcare-associated Infections, Mashhad, Iran, 2018. The competition took place in three rounds. The selected teams presented their projects in the first round and debated one by one in a knockout manner, while the jury reviewed their scientific content and presentation skills. In the second round, the top 5 projects competed for reaching the final stage, in which the teams presented their ideas in front of a panel of international IPC experts to determine the first three ranks. At the end of the contest, the participants gained valuable criticisms on how to improve their ideas. Moreover, by its motivating atmosphere, the contest created an excellent opportunity to promote IPC in medical schools.

Conclusions

Using innovation contests in pre-graduates is an innovative education strategy. It sensitizes medical students to the challenges of IPC and antimicrobial resistance and drives them to think about solutions. By presenting and defending their innovations, they deepen their understanding on the topic and generate knowledge transfer in both ways, from students to teachers and vice versa.

Train-the-Trainers in hand hygiene: a standardized approach to guide education in infection prevention and control

Background

Harmonization in hand hygiene training for infection prevention and control (IPC) professionals is lacking. We describe a standardized approach to training, using a “Train-the-Trainers” (TTT) concept for IPC professionals and assess its impact on hand hygiene knowledge in six countries.

Methods

We developed a three-day simulation-based TTT course based on the World Health Organization (WHO) Multimodal Hand Hygiene Improvement Strategy. To evaluate its impact, we have performed a pre-and post-course knowledge questionnaire. The Wilcoxon signed-rank test was used to compare the results before and after training.

Results

Between June 2016 and January 2018 we conducted seven TTT courses in six countries: Iran, Malaysia, Mexico, South Africa, Spain and Thailand. A total of 305 IPC professionals completed the programme. Participants included nurses (n = 196; 64.2%), physicians (n = 53; 17.3%) and other health professionals (n = 56; 18.3%). In total, participants from more than 20 countries were trained. A significant (p < 0.05) improvement in knowledge between the pre- and post-TTT training phases was observed in all countries. Puebla (Mexico) had the highest improvement (22.3%; p < 0.001), followed by Malaysia (21.2%; p < 0.001), Jalisco (Mexico; 20.2%; p < 0.001), Thailand (18.8%; p < 0.001), South Africa (18.3%; p < 0.001), Iran (17.5%; p < 0.001) and Spain (9.7%; p = 0.047). Spain had the highest overall test scores, while Thailand had the lowest pre- and post-scores. Positive aspects reported included: unique learning environment, sharing experiences, hands-on practices on a secure environment and networking among IPC professionals. Sustainability was assessed through follow-up evaluations conducted in three original TTT course sites in Mexico (Jalisco and Puebla) and in Spain: improvement was sustained in the last follow-up phase when assessed 5 months, 1 year and 2 years after the first TTT course, respectively.

Conclusions

The TTT in hand hygiene model proved to be effective in enhancing participant’s knowledge, sharing experiences and networking. IPC professionals can use this reference training method worldwide to further disseminate knowledge to other health care workers.

Optimizing compliance with surgical antimicrobial prophylaxis guidelines in patients undergoing gastrointestinal surgery at a referral teaching hospital in southern Iran: clinical and economic impact

BACKGROUND

Antibiotic prophylaxis is one of the major approaches to prevent surgical site infection. Despite the availability of international guidelines on it, the practice of antibiotic prophylaxis is still far from optimal. This study aimed to assess the impact of guideline implementation on the rational use of prophylactic antibiotics and its cost-saving effect in gastrointestinal surgery by clinical pharmacist intervention.

METHODS

A pre and post intervention study was carried out between October 2017 and June 2018 on patients who underwent gastrointestinal surgery in a major referral teaching hospital in Shiraz, southern Iran. The intervention phase consisted of revising the institutional guidelines for surgical antimicrobial prophylaxis, assigning a clinical pharmacist to the surgical department, and arranging several meetings with the surgical department regarding the appropriate utilization of antibiotics. Differences in antibiotic utilization in patients before and after the intervention phase were compared. Exposures were surgical antimicrobial prophylaxis timing and agents, and main outcomes were incidence of surgical site infection and length of hospital stay.

RESULTS

A total of 430 patients were included in the post intervention phase, while 445 patients were included in the baseline evaluation. Promoting appropriate antibiotic use in the post intervention group had the potential to decrease medication costs by reducing unnecessary prescriptions and duration of antibiotic usage (P<0.001). In the pre intervention group, the mean cost of antibiotic prescriptions was 11.5 times that of the post intervention group. Mean hospitalization in the pre intervention group was greater than the post intervention group (P<0.001). Furthermore, our data revealed that the rate of postsurgery infection in the post intervention group was 3.03%, while this rate was 6.76% in the preintervention group (P=0.01).

CONCLUSION

This study provides evidence that adherence to surgical antimicrobial prophylaxis guidelines increased the rational use of prophylactic antibiotics, with substantial cost savings in patients who underwent surgery.

Health care-associated infection surveillance system in Iran: Reporting and accuracy

BACKGROUND

Valid data are a crucial aspect of infection prevention and control programs. The aim of this study was to examine the accuracy of routine reporting in the Iranian Nosocomial Infection Surveillance System in intensive care units.

METHODS

A blinded retrospective review of general intensive care unit medical records was performed with a standard case-finding form. Infection control nurses (ICNs) were also interviewed to explore possible reasons for differences.

RESULTS

The results of 951 events in 856 medical records were assessed. Sensitivity, specificity, and positive and negative predictive values of routine surveillance were 27.5%, 97.2%, 69%, and 85.3%, respectively. The results indicate 82.2%, 68.4%, 62.7%, and 57.3% under-reporting of surgical site infections, urinary tract infections, bloodstream infections, and pneumonia, respectively. Over-reporting of approximately 8%-15% was detected in 4 types of health care-associated infections (HAIs). Misinterpretation of HAI definition, high ICN workload, and inactivity of infection control link nurses were the main causes of inaccurate reporting.

CONCLUSIONS

Under and over-reporting of HAIs are main challenges of HAIs reporting in Iran. Developing guidelines, empowering ICNs through specialized training and activating infection control link nurses are necessary to achieve more accurate data in the Iranian Nosocomial Infection Surveillance System.